This is a blog by a former CEO of a large Boston hospital to share thoughts about hospitals, medicine, and health care issues.

Friday, October 02, 2009

Kaizen Corner -- Inaugural edition

Our chief of medicine, Mark Zeidel, was one of our senior management group who took a course in Lean process improvement philosophy and techniques. He decided he would share what he was learning with his faculty and students, in the form of a section of each week's departmental newsletter named "Kaizen Corner".

Mark is an enthusiastic and excellent teacher, and there are already reports throughout his department of lots of use of Japanese terms! (Courses for the residents and interns will expand and reinforce these messages.) I reprint excerpts here from his June 9 inaugural edition and will give you some later editions for each of several days next week.

The hospital has engaged Greater Boston Manufacturing Partnership, Inc., to partner with Alice Lee and her staff in developing training in Toyota production and process improvement techniques for BIDMC. I am enjoying the privilege of taking one of the first courses, a series of 8 or 9 six hour sessions, (with homework) focused on the fundamentals of continuous improvement. The course is terrific, and is beginning to point to the way in which we can become a self-learning, continuously- improving organization of the kind that Steven Spear, our recent visiting lecturer, outlines in his book, Chasing the Rabbit. Members of our Department who are taking these initial courses include Ken Sands and Julius Yang.

To help spread an understanding of the principles of the Toyota system, I will outline elements in the Newsletter each week. We start with the Japanese term, kaizen: This means, “incremental improvement.” Kaizen is the continuous pursuit by all employees of ways to do their jobs better (more safely and reliably), faster (more efficiently, with less strain) and cheaper (at lower expense because there is less waste).

We will go forward with four critical concepts:

1. Customer first.Customers may be our patients, or referring physicians or the physicians we sign out to.

We strive to provide to each customer exactly what is needed and desired—immediately. This is summarized by the directive, “Produce the customer’s exact order immediately.”

The only acceptable level of quality from the customer’s standpoint is zero defects.

2. Employees are the most important resource.This means that we must strive to engage each and every employee in helping improve the work we do. We must help each employee to work creatively in our environment.

3. Direct observation as the path to improvement.Even after years of observation of a process, new discoveries as to how it can be improved can occur every day. If you want to improve something, go and see for yourself how it is working now, with an eye toward how it can be improved

4. Kaizen is for everybody, every day.We must make improvement part of everyone’s job, something that they do as part of their job, every day. This is the key to becoming a self-learning organization. We must make it possible and normal for people at the front lines to recognize when a process is not going as well as it could go, call it out and work with coworkers or management to fix it as soon as possible.

There is an enormous amount of content in this one page. Over the next series of newsletters, I will try to outline many of the critical elements of the Toyota system. I hope that these descriptions will help people become acclimated to some of these concepts, so we can move them from the minds of a few to the practice of all.

16 comments:

Anonymous
said...

Paul, I am curious about your reaction to the quote below from Christensen's book:

"Spending tens or hundreds of millions of dollars on six-sigma process consultants and IT systems will not make a significant difference in cost or quality until the solution shop and value-adding process activities of hospitals are housed in different models of care delivery."

Now, I have not finished this book, and I am not sure I will agree with it - but by the time I do finish it, this post will be old news. Hence my question at the moment.

He;s right about lots of things but not about this. Well, he is right about not spending millions of dollars on consultants, but implementation of Lean does not require that. We see improvements every day that make life better for staff and patients and that also sometimes save money. I think Gary Kaplan at Virginia Mason in Seattle would say the same thing.

Clay's comments about the structure of the industry, however, are right on target.

Having read a bit more, I get the impression that he is saying that as long as the industry model is structurally deficient, process improvement systems such as Lean/Six Sigma can only make improvements around the periphery, not the earthshaking transformations which achieve large gains for the $$/effort expended. He may be right in this regard.It's similar to the old hospital saw that you can't use IT systems simply to automate bad work processes - you have to transform the processes first.(From personal experience, this is much more easily said than done, particularly with off the shelf proprietary hospital IT systems, which basically force you to organize your work processes the computer's way, not your way.)

I am looking forward to the integration chapter. Thanks for your thoughts.

The more things change, the more they remain the same. The work of Dr. W. Edwards Deming is the root of Toyota's kaizen process. I recommend revisiting the 14 principles presented in his book "Out of the Crisis":

1. Create constancy of purpose toward improvement of product and service, with the aim to become competitive and stay in business, and to provide jobs. 2. Adopt the new philosophy. We are in a new economic age. Western management must awaken to the challenge, must learn their responsibilities, and take on leadership for change. 3. Cease dependence on inspection to achieve quality. Eliminate the need for inspection on a mass basis by building quality into the product in the first place. 4. End the practice of awarding business on the basis of price tag. Instead, minimize total cost. Move towards a single supplier for any one item, on a long-term relationship of loyalty and trust. 5. Improve constantly and forever the system of production and service, to improve quality and productivity, and thus constantly decrease costs. 6. Institute training on the job. 7. Institute leadership (see Point 12 and Ch. 8 of "Out of the Crisis"). The aim of supervision should be to help people and machines and gadgets to do a better job. Supervision of management is in need of overhaul, as well as supervision of production workers. 8. Drive out fear, so that everyone may work effectively for the company. (See Ch. 3 of "Out of the Crisis") 9. Break down barriers between departments. People in research, design, sales, and production must work as a team, to foresee problems of production and in use that may be encountered with the product or service. 10. Eliminate slogans, exhortations, and targets for the work force asking for zero defects and new levels of productivity. Such exhortations only create adversarial relationships, as the bulk of the causes of low quality and low productivity belong to the system and thus lie beyond the power of the work force. 11. a. Eliminate work standards (quotas) on the factory floor. Substitute leadership.b. Eliminate management by objective. Eliminate management by numbers, numerical goals. Substitute leadership. 12. a. Remove barriers that rob the hourly worker of his right to pride of workmanship. The responsibility of supervisors must be changed from sheer numbers to quality.b. Remove barriers that rob people in management and in engineering of their right to pride of workmanship. This means, inter alia," abolishment of the annual or merit rating and of management by objective (See Ch. 3 of "Out of the Crisis"). 13. Institute a vigorous program of education and self-improvement. 14. Put everybody in the company to work to accomplish the transformation. The transformation is everybody's job.

Following the Deming Cycle of Plan-Do-Check-Act is still a very good way to accomplish constant improvement.

If we wait for structural change in the industry before attempting improvements in our own hospitals, nothing will happen. There is a lot that can be done to improve patient care and the work environment in our places.

Paul, I just had a question about concept #1. How does this concept work in the environment of multiple customers and differing priorities? We can't, of course, fulfill every request immediately. Somebody has to wait, because other priorities must come first. It doesn't seem right to short-change the patient with whom I am currently working so that I can fulfill a non-urgent request from another patient. And what about the poor patient with minimal needs whose care is continually interrupted because the caregiver's other patient has critical urgent needs? Immediacy for one patient thus means delay or interruption for another. I think "customer first" is a great concept, but asking for immediacy seems unrealistic for health care providers. I am not sure how you get zero defects while still giving immediate responses. Doesn't someone generally come up short in that scenario?

Paul;No, I wasn't at all suggesting we wait for structural change! (we would die of old age..... (:) I am actually a very impatient person regarding inertia surrounding change in health care, which is what attracted me to your blog in the first place. But Christensen's statement has given me the glimmerings of his “hospital-within-a-hospital” idea; that one can separately organize the Lean-type improvements you are trying to make into improvements in your value-added processes (which, frankly, include most of what goes on), and, separately, improvements in the solution shop model, such as your prostate team, or such as how diagnostic consults on inpatients are optimized. I am sure you are already informally doing it this way, but formally conceptualizing it as such may make Lean seem less complex.

"In our BIDMC multidisciplinary clinic a new patient will typically spend 2 to 3hours speaking to 2 or 3 physicians from different specialties (urology, radiation oncology, medical oncology) but instead of having incentives for such patient-centered care, docs and hospitals are punished for having multiple specialists see a patient because payors/providers (eg Medicare) limit facility fee……"

made me wonder, does the patient see these specialists sequentially, all at once, or both? In the setting of playing by the dictated rules, I would think sequential appointments in the same building could be coded as separate visits. Of course, the most patient-centric way is for the specialists to review the case together first, then see the patient together; so then you get penalized. But when payments eventually become organized by episode of care, you will win in the end.....

Super question. An organization that is well versed in Lean -- and we are just beginning -- incorporates those principles all the time. It BECOMES the way work is done. It is not an extra effort. It is the way.

I think they see all three at the same time, or at worst, two. Yes, the MDs give up revenue in that setting, but as Dr. Sanda says, "It is the right way to take care of a patient. That's more important."

Simplified answer for facilities fees, as I understand things, is that there is virtually no rationale for any specific charge at the hospital level. They are simply a way of covering the large fixed costs of a hospital by assigning them to individual items. They have no more relation to the actual direct costs of providing care than charges for long distance calls used to have with regard to the telephone company's actual direct costs of delivering a phone call. That being said, you need some way to cover all those fixed costs -- which are necessary to ensure that plant and equipment and personnel will be there when it is needed.

As economists will tell you, there is no economically correct way to assign fixed and common costs of this nature. There are dozens of ways to do so, all of which have the same degree of accuracy! So, over the years, Medicare + insurance companies have accepted the cost assignment patterns that you see today.

With all due respect, Mr. Levy, who cares how many Japanese words are being used? The over-reliance on Japanese terms (kaizen, heijunka, poka yoke, etc. etc. etc.) only makes Lean seem mysterious and foreign. It's a barrier. I hope you don't have a "sensei" helping you, God forbid.